Texas § IN.1451.208 - PRIOR AUTHORIZATION OF DENTAL CARE SERVICES

§ IN.1451.208. PRIOR AUTHORIZATION OF DENTAL CARE SERVICES

PRIOR AUTHORIZATION OF DENTAL CARE SERVICES. (a) For purposes of this section, "prior authorization" means a written and verifiable determination that one or more specific dental care services are covered under the patient's employee benefit plan or health insurance policy and are payable and reimbursable in a specific stated amount, subject to applicable coinsurance and deductible amounts. The term: (1) includes preauthorization or similar authorization; and (2) does not include a predetermination as defined by Section 1451.207 (c). (b) For services for which a prior authorization is required, on request of a patient or treating dentist, an employee benefit plan or health insurance policy provider or issuer shall provide to the dentist a written prior authorization of benefits for a dental care service for the patient. The prior authorization must include a specific benefit payment or reimbursement amount. Except as provided by Subsection (c), the plan or policy provider or issuer may not pay or reimburse the dentist in an amount that is less than the amount stated in the prior authorization. (c) An employee benefit plan or health insurance policy provider or issuer that preauthorizes a dental care service under Subsection (b) may deny a claim for the dental care service or reduce payment or reimbursement to the dentist for the service only if: (1) the denial or reduction is in accordance with the patient's employee benefit plan or health insurance policy benefit limitations, including an annual maximum or frequency of treatment limitation, and the patient met the benefit limitation after the date the prior authorization was issued; (2) the documentation for the claim fails to reasonably support the claim as preauthorized; (3) the preauthorized dental care service was not medically necessary based on the prevailing standard of care on the date of the service, or is subject to denial under the conditions for coverage under the patient's plan or policy in effect at the time the service was preauthorized, because of a change in the patient's condition or because the patient received additional dental care services after the date the prior authorization was issued; (4) a payor other than the employee benefit plan or health insurance policy provider or issuer is responsible for payment of the claim; (5) the dentist received full payment for the preauthorized dental care service on which the claim is based; (6) the claim is fraudulent; (7) the prior authorization was based wholly or partly on a material error in information provided to the employee benefit plan or health insurance policy provider or issuer by any person not related to the provider or issuer; or (8) the patient was otherwise ineligible for the dental care service under the patient's plan or policy, and the plan or policy provider or issuer did not know and could not reasonably have known that the patient was ineligible for the dental care service on the date the plan or policy provider or issuer preauthorized the dental care service. Added by Acts 2019, 86th Leg., R.S., Ch. 1290 (H.B. 2486 ), Sec. 4, eff. September 1, 2019.